document (1)

วารสาร
นิ พ นธ์ ต ้ น ฉบั บ
ORIGINAL ARTICLE
เทคนิ ค การแพทย์ แ ละกายภาพบำ � บั ด
JOURNAL OF MEDICAL TECHNOLOGY AND PHYSICAL THERAPY
อิทธิพลการคลาย sacrotuberous ligament ด้วยการทดสอบ Faber
ในคนสุขภาพดี
พรสิริ ประเสริฐกิจกุล1 ชมพูนุท สุวรรณศรี1* และ อรรถพร มงคลภัทรสุข1
Received: February 11, 2018
Revised: June 3, 2018
Accepted: June 11, 2018
บทคัดย่อ
วัตถุประสงค๋: เปรียบเทียบระยะห่างระหว่าง head of fibula ถึงเตียงที่ใช้ทดสอบด้วย Faber ก่อน และ หลังการคลาย
sacrotuberous ligament (ST ligament).
วิธีการ : ผู้เข้าร่วมวิจัยสุขภาพดี 30 คน (เพศชาย 8 คน และ เพศหญิง 22 คน) ได้รับการทดสอบ Faber โดย
นักกายภาพบ�ำบัด พบความตึงของ ST ligament แตกต่างกัน ดังนี้ ข้างขวา, ซ้าย เท่ากับ 12 และ 18 ข้าง ตามล�ำดับ
โดยท�ำการวัดระยะห่างระหว่าง head of fibula ถึงเตียง ก่อน และ หลังการคลาย ST ligament โดยนักกายภาพบ�ำบัด
อีกท่าน
ผลการด�ำเนินการ : ค่าเฉลี่ยของระยะห่างระหว่าง head of fibula ถึงเตียง ก่อน และ หลังการคลาย ST ligament
เท่ากับ 12.42 ± 4.30 เซนติเมตร และ 9.00 ± 4.71 เซนติเมตร ตามล�ำดับ และ มีความแตกต่างกันอย่างมีนัยส�ำคัญ
ที่ p <0.001.
สรุป : การคลาย ST ligament สามารถลดระยะห่างระหว่าง head of fibula ถึงเตียง ในการทดสอบด้วย Faber
ในคนสุขภาพดี
ค�ำย่อ : ST ligament = sacrotuberous ligament, QL = quadratus lumborum, SIJ = sacroiliac joint, KLIMB
= Kinematic linkage muscle imbalance
ค�ำส�ำคัญ: Sacrotuberous ligament, Sacroiliac joint, Muscle linkage, Faber test, Sign of 4
คณะกายภาพบำ�บัด มหาวิทยาลัยมหิดล 198/2 ถนนสมเด็จพระปิ่นเกล้า แขวงบางยี่ขัน เขตบางพลัด กรุงเทพ 10700
*ผู้รับผิดชอบบทความ
1
J Med Tech Phy Ther  Vol. 30 No. 3  September - December 2018
381
วารสาร
นิ พ นธ์ ต ้ น ฉบั บ
ORIGINAL ARTICLE
เทคนิ ค การแพทย์ แ ละกายภาพบำ � บั ด
JOURNAL OF MEDICAL TECHNOLOGY AND PHYSICAL THERAPY
Influence of releasing sacrotuberous ligament to Faber test
in healthy individuals
Pornsiri Prasertkijkul1, Chompunoot Suwanasri1* and Attaporn Mongkonpattarasuk1
Received: February 6, 2018
Revised: May 14, 2018
Accepted: Jun 4, 2018
Abstract
Objectives: To compare perpendicular distances from the head of fibula to the examining table on the
Faber test before and after releasing sacrotuberous ligament (ST ligament).
Method : Thirty healthy people participated in this study (8 males and 22 females) volunteered.
A physical therapist (PT) performed the Faber test to identify whose leg was tighter; 12 right and 18 left
sides. A PT measured the distance between head of fibula to the table surface during the Faber test
before and after the ST ligament was released by another PT.
Results : Mean distance between head of fibula to table before releasing ST ligament was 12.42 ± 4.30
centimeters, while after release the distance STL was 9.00 ± 4.71 centimeters a significant difference
(p <0.001).
Conclusion : The effect of released ST ligament could decrease the distance between head of fibula
and table surface in the Faber test
Abbreviation : ST ligament = sacrotuberous ligament, QL = quadratus lumborum, SIJ = sacroiliac joint,
KLIMB = Kinematic linkage muscle imbalance
Keywords: Sacrotuberous ligament, Sacroiliac joint, Muscle linkage, Faber test, Sign of 4
Faculty of Physical Therapy, Mahidol University, Bankok, Thailand
*Corresponding author: (e-mail: [email protected])
382
วารสารเทคนิคการแพทย์และกายภาพบำ�บัด  ปีที่ 30 ฉบับที่ 3
กันยายน - ธันวาคม 2561
Introduction
Mobility of the sacroiliac joint (SIJ) is
mainly passive structure, occurs in three planes
with a few degrees of movement. This motion is
only 0.5-1.6 mm for translation and up to 4
degrees for rotation according to X-ray analysis(1).
The main movement of SIJ is rotation of the
sacrum relatively to the iliac bone. Although no
muscle moves the SIJ directly, the movements of
this joint depend on the rectus femoris, adductor
muscles of hip joint, sartorius, iliacus(2), gluteus
maximus(4) and hamstrings(4,5) (especially bicep
femoris(3)) muscle.
Besides these muscles, there are some
ligaments so-called “self-bracing the pelvis”(6). The
important ligaments which have an influence on
the SIJ such as sacrotuberlous (ST) ligament
(connecting the sacrum to ischial tuberosity(3)),
long dorsal sacroiliac ligament (connecting the
sacrum to posterior superior iliac spine) and
sacrospinous ligament(7) (connecting the ischial
spine to the sacrum-coccyx).
The ST ligament is one of important
structures of the SIJ attached from the lower
lumbar spine to posterior portion of the iliac crest.
This ligament plays 2 roles: 1) to stabilize the SIJ
while this joint is moving and 2) to control the
range of movement of the SIJ(2,3). Hammer N. et al
2013 found that if ST ligament has the tension, it
decreases of nutation. If the long dorsal sacroiliac
ligament has the tension, sacrum is happened the
counternutation(1). Sprains of the SIJ might also
result from imbalance forces acting on ilium.
The relationship between SIJ to the part
of the lower limb has been previously shown. The
study of Van Wingerden et al found that there
was a part of the long head of biceps femoris
which was attached to the ST ligament(8). Thus it
was presented that the role of ST ligament could
affect to the movement of the lower limb.
Common problem of the pelvic girdle
pain1 comes from low back pain(7) however, the SIJ
was another cause of pain at pelvic girdle, also.
Fortin JD. et al located of pain in SIJ by injected
in healthy subjects. Pain from SIJ spread
approximate caudally 10 cm. and 3 cm. laterally
from posterior superior iliac spine(9). The clinical
test for SIJ are many test such as Gillet, Gaenslen’s, Spring, Distraction /compression, Patrick’s
or sign of four or Faber test.(10)
The Faber test is one of the mobility test
for SIJ combining ipsilateral hip flexion, abduction
and external rotation positioning the heel on the
contralateral knee in supine. The specificity,
sensitivity of Faber’s test is 81-100%, 50-77%,
respectively, is reviewed by Stuber KJ (11).
Meanwhile this test is positive if the patient felt
pain at the pelvic girdle area. If there are only the
tension, and the distance between knee and the
table was higher than the other side. This distance
showed that it may be tightened from the
adductor muscle of hip joint or tension from ST
ligament.
Releasing the ST ligament would decrease
nutation has been anecdotal but the evidence to
support this notation is still lacking. Seemingly the
ST ligament has been overlooked. There was no
other study previously investigating this ligament.
Therefore, this study aimed to investigate the
immediate effect of releasing the ST ligament on
as measured by the distance between head of
the fibula to the table in Faber’s test.
J Med Tech Phy Ther  Vol. 30 No. 3  September - December 2018
383
Material and Methods:
Participants :
Thirty asymptomatic male and female
volunteers, 19-26 years of age, were recruited. This
protocol was approved by the Institutional Review
Board, Mahidol University (MU-CIRB 2015/073.1405)
and was registered at the Thai Clinical Trail
Registry (TCTR) as an identification number TCTR
20170412002. The amount of volunteers was
calculated the sample sized with drop out 20%.
Participants were excluded due to have past
history of musculoskeletal symptoms (e.g.
scoliosis, fibromyalgia, pain at any regions, and
instability of lower extremities caused by ligamentous injury, injury or trauma to lower extremities),
endocrine disease, rheumatoid arthritis, pregnancy
and had menstruation on the data collection day.
Instrumentation : A tape measure, a disappear
ink pen (see the ink when use the ultraviolet light),
Standard goniometers
A
years). The inter-reliability of the distance
between head of fibula and the table in Faber
test of the first (PT1) and second physical
therapists (PT2) were 0.867. So, PT2 who was
chosen for measure the distance, the
intra-reliability of the PT2 was 0.947. This physical
assessment was aimed to investigate which the
participant’s side had more ST ligament tightness
by Faber test, compared to the other side. This
particular side was chosen to receive ligament
release.
Faber test ; we did the test both side to compare
which side have tension
The first physical therapist (PT1) set the
Faber test position (the side of test leg is flexed,
abducted, and external rotation of hip joint, the
heel on the other side of knee in supine lying)
and placed one hand onto the anterior superior
iliac spine (ASIS) of the opposite leg, the other
hand on the top of knee joint of the test leg. Then
lowered the test leg until the ASIS in opposite
side lifting up. The PT1 decided which leg was
more tighten. Then the second physical therapist
(PT2) measured the distance between the head
of fibula of the test leg and the table using a tape
measure. (Figure 2)
B
Figure 1 Instruments A = Tape measure, B = disappear
ink pen
Procedure :
Prior to participate in this study, the
researchers explained details of data collection
to the participants and the latter signed inform
consent.
Each participant initially received a battery
of tests for physical assessment from two
experienced physical therapists (more than 5
384
Figure 2 The second physical therapy measured
the distance between the head of fibula of the
test leg and the examining table
วารสารเทคนิคการแพทย์และกายภาพบำ�บัด  ปีที่ 30 ฉบับที่ 3  กันยายน - ธันวาคม 2561
Palpation of ST ligament
The position of the participants were side
lying, flexion hip and knee 90° of the ST ligament
tension side. The lower leg extended the knee.
The PT1 palpated the ST ligament by tracking
imaginary line which was perpendicular to the
midpoint between ischial tuberosity and sacrum
1 inch. (Figure 3)
Figure 4 Release ST ligament by place the
dominant side on the PT’s upper thumb
Figure 3 The ST ligament (A) which showed the
tracking imaginary line from the midpoint of ischial tuberosity to sacrum 1 inch.
In our pilot study, we investigated an
agreement of ST ligament in ten subjects by
palpation between PT1 and PT2. These two
physical therapists marked ST ligament twice for
each person (by a disappear ink pen). The
agreement of palpation of the ST ligament by
marked 2 times of the PT1 was 100% (PT2 was
80% of the agreement). If two marked were more
than 50% of overlapped point, it mean that 100%
coincide.
PT1 placed both thumbs on the ST
ligament and slightly release pressure from the
shoulder of the upper thumb (the dominant
thumb was on the another thumb) (Figure 4)
Data analysis
The data were normally distribu
tion by Kolmogorov Smirnov test. We performed
statistical analysis using SPSS (version 19).
Comparison of distance from head of fibula to
examining table between pre and post releasing
ST ligament was performed using paired t test.
Results
Thirty participants (8 males and 22
females). Twelve persons had more ST ligament
tension on the right, while the rest had more
tension on the left. Descriptive data of their
characteristics were displayed in Table 1
Table 1 Participants’ characteristics (n=30)
Characteristics
Age (years)
Weight (kilograms)
Height (centimeters)
BMI (kilogram/meter2)
Leg-dominant (right/left)
J Med Tech Phy Ther  Vol. 30 No. 3  September - December 2018
Mean + SD
20.40 ± 1.10
54.65 ± 9.62
162.42 ± 7.72
20.65 ±2.90
12/18
385
The mean of distance between the head
of fibula to the table surface before releasing ST
ligament was 12.42 ± 4.30 centimeters, while that
after releasing such ligament was 9.00 ± 4.71
centimeters. (Table 2) The means of such distance
between pre- and post-releasing the ST ligament
were significantly different (tdf=29 = 5.26, p > 0.00).
(Table 3) The perpendicular distance between
the femoral condyle and the table in Faber test
of the post-test after release ST ligament was less
than that of the pre-test.
Table 2. Mean, Standard deviation and standard
error mean of the distance between head of
fibula to couch surface before and after releasing
ST ligament in 30 healthy subjects
position
Faber before
Faber after
Mean
(cm.)
SD
Std.
Error
Mean
12.42
9.00
4.30
4.71
.78
.86
Discussion and Conclusion
The present study was to evaluate the
effect of releasing ST ligament on the distance of
head of fibula measured in the Faber test position.
Mean and standard deviation between head of
fibula to table surface before and after releasing
ST ligament were 12.42, 9.00, respectively. This
result of this present study demonstrate that
releasing ST ligament significantly increased
position of hip in Faber test, by (p<0.0001). Our
participants were healthy subjects who were not
pain during the Faber test position. However, they
showed the different tension of legs by the
distance from head of fibula to the table.
386
Function of the SIJ is to transfer loads between
the spine and legs(8), allow shock and shear
absorption and minimize energy for gait. Changing
from quadrupeds to bipeds for allowing activities
in humans (e.g. standing, sitting, walking)
adaptation of pelvis (e.g. ilium, pubis, ischium,
ligaments and muscle are increased stability of
pelvic girdle(12). For stability, 1993 Snijders CJ. et
al. (6) suggested a self-bracing effect or phenomenon
which protects the SIJ against shear loading.
The model included a large numbers of muscles
and ligaments such as the gluteus maximus,
piriformis muscle, ST, sacrospinal, and long dorsal
and interosseous sacroiliac ligaments, which can
be tested with the Faber’s test(6).
The Faber test or sign of four is the
standard special test for assessment of sacroiliac
joint(13,14). Its position of knee is flexed, ankle is
placed on the opposite of thigh, the hip in flexion,
abduction and external rotation. Dreyfuss 1996,
Broadhurst, 1998, Broadhurst, 1998 found that the
sensitivity were 69%, 77%, 50%, respectively, and
the specificity were 16%, 100%, 100%, respectively(11).
If the distance of the knee from the table was
high, the limitation of SIJ may be the secondary
problem of low back pain. Decreased tension of
the ST ligament should increase sacrum nutation(7)
and LBP region related to this ligament(15). This
research was conducted to released the ST
ligament in 30 healthy subjects at the affected
side which had ST ligament more tighten than the
other side. The mean and standard deviation of
the distance from head of fibula to the examining
table in Faber’s test before-after releasing ST
ligament were 12.42±4.3, 9.0±4.71 cm, respectively.
วารสารเทคนิคการแพทย์และกายภาพบำ�บัด  ปีที่ 30 ฉบับที่ 3  กันยายน - ธันวาคม 2561
Table 3 Paired T test between before and after releasing ST ligament in 30 healthy subjects.
Paired Differences
Mean
Faber before-after
3.42
SD
3.56
Std.
Error
Mean
95% Confidence Interval
of the Difference
.65
The ST ligament which attached sacrum,
ilium and coccyx to ischial tuberosity, has close
anatomical relations with erector spinae/ multifidus
gluteus maximus, biceps femoris muscle,
contralateral of thoracolumbar fascia and
latissimus dorsi13. The main movements in the SIJ
are forward-backward rotation of sacrum relative
to the iliac bones or nutation-counternutation.
Nutation is the movement for prepare the pelvis
for increased loading by slackened of ST ligament.
This study demonstrated that releasing the ST
ligament could be increased the action of Faber’s
test. If low back pain patients who were suspected
of counter-nutation of sacrum, releasing ST
ligament may decreased pain.
Acknowledgement : The concept of this study
follows the Kinematic Linkage Muscle Imbalance
which is originated from Ass. Prof. Preecha
Danvarjor.
Lower
Upper
2.09
4.74
t
Sig. (2-tailed)
5.26
.0001
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